Blue collar concierge medicine is for everyone

Part of a series.

Is concierge medicine for everyone or is it just for the rich, the 1%? Most people assume it is for the elite and cannot be afforded by the common man, the masses. That is unfortunate because in many cases it can be quite affordable. Here are three examples.

AtlasMD in Kansas City and others like it think of themselves as “blue collar” concierge practices. According to AtlasMD physician Dr. Doug Nunamaker,“We realized that insurance paying for primary care is akin to using car insurance to try to pay for gasoline. It’s something that’s otherwise fairly affordable until you try to pay for it with insurance: My premiums would be much higher because they wouldn’t know how much gas I would need, they would tell me where to get gas, and I’d have to preauthorize trips out of town.”

AtlasMD physicians have 600 patients each. Monthly fees: 20 to 44 years — $50 a month, 45 to 64 — $75 a month, 65 and older — $100 a month, children to 19 years — $10 a month. Generic medicines are available at wholesale prices.

In Erie, a working class city in northwestern Pennsylvania, the Izbicki brothers also began such a “blue collar” membership practice. Just out of training in family medicine in 2005, they first worked for another practicing physician and then the local hospital, in each case being frustrated that they could not spend enough time with each patient.  They started their own practice using the typical insurance-based business model and soon had about 4000 patients between them. They were back to seeing too many patients for too short a time each. Dr. Jon Izbicki told me, “We were bitter, frustrated. We were in a failed profession. It was so bad that we really had to take a risk. We knew that what patients want more than anything else is uninterrupted time with their PCP and with that to build a level of confidence. They want relationship-centered care.”

They converted in June, 2013. They chose to call their practice direct primary care given the fiscal conservatism of Erie. Not all of their patients were pleased; less than 20% joined initially. But over time their practice numbers have climbed to about 1000, or 500 each.

The Izbicki brothers charge $780 per year for unlimited primary care, payable as $65 monthly or annually with a discount. Visits are as long as needed and usually the same or the next day. They have developed contracts with clinical laboratories for highly discounted testing and radiology. They purchase generic drugs at wholesale prices and sell them to their patients at the same price. For many patients, especially those with multiple chronic illnesses who are taking 5 to 7 prescription medications, this can save as much or more than the annual membership fee. It is this latter factor than especially encourages Medicare enrollees to join.

“Perhaps the term ‘complex care physician’ would be better than primary care physician as it more closely relates the work of the doctor, especially with these patients with highly complex, serious illnesses.”

Not everyone has a sizable practice from which to convert. For younger physicians, with no base of patients to draw from, it can be a challenge to get started. In Lawrence, Kansas, Dr. Ryan Neuhofel began a membership practice called NeuCare right out of his residency training in 2012. He had decided while in medical school and residency that he did not want to be in a typical insurance-based practice. He told me, “I saw that most PCPs did not have fulfilling careers; they spent enormous time in administrative tasks rather than actually working with their patients. I knew I wanted to do primary care but it had to be in a model that let me earn a decent living yet let me give real quality care in a compassionate manner.”

“It was a real gamble to go straight into this. I had no patients and no reputation in Lawrence. My practice built slowly at first but is gaining momentum now.”

The demographics of his locale are individuals with less than the national median income so his practice is “more like a safety net clinic.” About 70-80% are uninsured and a very large number have complex, chronic illnesses — “a lot more than I anticipated.” His monthly fee is $30 and $40 rising to $50 for those over age 60; he charges $100 for a family of four with $10 more for each extra child. He buys medications from wholesalers. He finds that the savings for some of his patients with multiple prescriptions can be literally hundreds of dollars per month for a family, far outweighing the monthly membership fee. Now a few employers have noticed and decided to offer his services as a benefit to their employees who take out a high deductible policy.

“I see this as a real source of growth for my practice and the real long term growth for the whole direct primary care concept. It allows employers to initiate a high deductible policy yet give the employee access to quality primary care at no added cost. This is especially important for the person with lots of chronic illnesses personally or in the family.”

Asked about income once his practice is filled out, “I will be earning about average for a family practice physician in this area and that is just fine with me.”

These three practices demonstrate that direct primary care by whatever name can be affordable to most individuals and families and in many cases actually save money — not to mention a return to relationship-based medicine.

Blue collar concierge medicine is for everyoneStephen C. Schimpff is a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center, senior advisor to Sage Growth Partners and is the author of The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You.

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  • Mike Henderson

    I would emphasize that direct primary care can work for the average patient that needs primary care. No, this isn’t a magical solution that works for every single person in America. From my perspective as an internist, the high costs and mediocre quality of medicine delivered is due to the influence of insurance companies. They make it very difficult to provide what patients need.

  • HJ

    I don’t see how spending an extra $900 a year for primary care saves money. I saw my doctor once last year.

    In my area direct pay is $170 a month for someone my age.

  • Patient Kit

    Another round of trying to sell this DPC model to “everyone”. I’ll try to exercise restraint and only ask a couple of very specific questions:

    1). Are you saying that most DPC doctors will be fine with treating mostly complex patients? And that they will spend all the time each complex patient needs for one tiny monthly fee, say $75?

    2). Since most patients with complex medical problems will likely need multiple specialists, how would specialists be paid for in this DPC/catastrophic insurance model?

  • querywoman

    Strange – children only $10 per month? Children can be complicated, especially babies during the first 12 months.
    I left Texas welfare in the early 2000s.
    The State of Texas used to pay about $550 per month as Medicaid premium in the first year of life: vaccines, frequent illnesses with visits, etc.

  • Suzi Q 38

    I would join if I could keep my regular insurance for complex medical problems, tests, and hospitalizations.
    I believe in this idea because I know I am worth getting quality care.
    If you are getting it with your insurance already, why change?
    If you are getting lousy care and not enough time with your PCP, I say it is worth giving it a try if you can afford it.

  • John C. Key MD

    DPC practices are still evolving. I started mine six months ago. The concierge model didn’t work for me–so we see patients at a deeply discounted FFS rate–$49 initial visit, $40 followups. Also available after hours and on weekends. Discounted lab work too; procedure charge $10 if we use consumable supplies. Our clientele is primarily the working poor–make too much for Medicaid and free clinics, not enough to pay usual insurance-centric rate. Patients are really grateful and practice is growing slowly and steadily. Not sure what the future will bring but we are ready to make modifications as necessary for better services. One thing is sure: it won’t include processing any form of third party pay.

    • DeceasedMD

      Is that really covering your costs? But I agree that is a more sane approach not taking medicare etc. Best of luck.

    • Patient Kit

      What happens to your patients if they need to see specialists? That’s one of my big concerns about DPC. What do you do if, for example, you suspect one of your patients has cancer?

      • John C. Key MD

        Sorry for the delay in reply. There are several alternatives to specialty referral short of consigning patients to the maw of CorpMed or government. Personally I have a network of specialists to whom I can refer cases that I can’t handle myself. I’ve been doing it so long I don’t shy away from most chronic or chronic/complex problems. Telephone consultations can be helpful too. There are many ways to skin a cat.

  • John C. Key MD

    What’s to discuss? You hang up the shingle, Marcus Welby style, and serve all comers. Help all you can. Chronic, acute, all are welcome. Time for doctors to “man-up”, or “doctor up” as the case may be.

    • Lisa

      One thing I would like to hear discussed is how a DPC practice can work with a high deductible insurance policy. How does a patient who pays for a DPC practice get the fees he paid counted against his insurance deductible? Or does someone like you, who runs a FFS DPC practice provide a billing slip that a patient can submit to their insurance so it would be counted against the deductible?

      Years ago, we had a high deductible insuranc policy. That was the year my son broke his leg. We paid cash for all the expenses related to his broken leg, then I submitted all the receipts (which had billing codes etc) and submitted them to the insurance company. They counted against the deductible.

      If the fees for a DPC practice can be counted against the deductible for a high deductible insurance policy then paying such fees, over and above the insurance premium makes more sense.

      • John C. Key MD

        Good question. It hasn’t come up in my practice since none of my patients have any type of insurance. Of course one of the things that makes DPC an economic winner is that all of the cost-enhancing features of insurance–software, coding, billing–are all eliminated. For me it hasn’t come up but my basic John Galt outlook says to have NOTHING to do with any insurance plan because they and CMS are 90% responsible for the mess we now have.

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